Compatible Frameworks? Health Impact Assessment and the Policy Sciences Katrina Smith Korfmacher, PhD Associate Professor of Environmental Medicine Director, Community Outreach and Engagement Core Environmental Health Sciences Center University of Rochester

PRESENTATION GOALS: How is this framework compatible with a policy sciences perspective on problem solving? What can/has the policy sciences contribute to this framework? What potential does this framework have for expanding the practice of the PSF (explicitly or not)

Overview Health in All Policies (HiAP) Health Impact Assessment (HIA) and Policy Sciences Frameworks Rochester’s Local Waterfront Revitalization Program (LWRP) Healthy Waterways Project HIA and PS, revisited

Factors Responsible for Population Health Health status is determined by: genetics (5%), health care (10%), behavior (30%), Social Conditions (55%) - WHO Commission on the Social Determinants of Health (2008)

Health In All Policies (HiAP) Many public decisions affect health - not only health policies! BUT….few non-health decisions even consider health outcomes How can we promote health through non- health policies? “Health in All Policies” (HiAP) Health Impact Assessment (HIA): one way to support HiAP

Health Impact Assessment (HIA) DEFINITION: “A combination of procedures, methods and tools that systematically judges the potential, and sometimes unintended, effects of a policy, plan, program or project on the health of a population and the distribution of those effects within the population. HIA identifies appropriate actions to manage those effects.” -International Association for Impact Assessment, 2006

History of HIAs Europe, Canada, New Zealand US: California, Alaska…. Human Impact Partners (www.humanimpact.org) PEW/RWJ Foundation (www.healthimpactproject.org)

HIA and Determinants of Health Affect health determinants like: How does the proposed project, plan, policy Housing Air quality Noise Safety Social networks Nutrition Parks and natural space Private goods and services Public services Transportation Livelihood Water quality Education Inequities and lead to health outcomes

Incorporating Health into Decision-Making The world would look different if we considered health impacts of decisions on… Development Farm Policy Incarceration Immigration Ports Education

HIA Examples from other states Alaska - North Slope Oil Development: HIA led to compromise lease plan; reduced impacts on hunting and fishing and avoided litigation Illinois - Smart Metering in Chicago: showed health risks from automatic electricity disconnects; now require site visit prior to shutoff and monitor impacts on low income people CA -Senior Housing in Oakland: predicted respiratory problems from air pollution; developer incorporated central air filtration and moved air intake away from high traffic area. According to one recent estimate, caring for a single patient with very poorly-controlled asthma can cost as much as $8,880 per year — roughly half the price of conducting this HIA.3

An ANALYSIS that… A PROCESS that… But what IS HIA??? Clarifies health effects of a proposed project, plan or policy Includes quantitative and/or qualitative information Highlights health disparities; makes health impacts explicit Considers multiple health outcomes Provides recommendations Shapes public decisions & discourse A PROCESS that… Engages & empowers community Builds consensus Builds relationships & collaborations

Steps of a HIA Screening Determines the need and value of a HIA Scoping Determines which health impacts to evaluate, methods for analysis, and a workplan Assessment & Recommendations Provides: 1) a profile of existing health conditions 2) evaluation of potential health impacts/alternatives 3) strategies to manage identified adverse health impacts Reporting Includes: 1) development of the HIA report 2) communication of findings & recommendations Monitoring Tracks: 1) Process: impacts on decision-making processes and the decision 2) Outcomes: impacts of the decision on health determinants

HIA and the Policy Sciences: Problem Orientation Screening Clarifying goals Scoping Assessment & Recommendations Describing trends Analyzing conditions Projecting developments Inventing, evaluating, and selecting alternatives Reporting [Social process] Monitoring HIAs are only conducted when likely to affect pending decision

-HIA is a collaborative process WHO does HIA? -HIA is a collaborative process -HIA may be LED by: health departments, planners, developers, consultants, community members, or interest groups -HIAs involve: The public for relationship building, capacity for advocacy, and empowerment Public health and other agencies for relationship- building, data, information, and resources Decision-makers/industry to ensure that recommendations are realistic and account for the practical, economic, and technical limitations on the decision at hand

HIA and Policy Sciences: standpoint Goal is to be a source of “objective information” Normative orientation toward ‘equity’ Identify ‘vulnerable populations’ Assess distribution of health impacts Aim to reduce health disparities Recommendations and Reporting are intended to influence decisions (analysis/advocacy)

HOW do HIAs Assess? Conduct a literature review Find out about other communities’ experiences Gather existing data or conduct new analysis on health, environmental and social indicators Compare data to existing regulatory criteria, standards, & benchmarks Utilize community expertise - e.g., focus groups, surveys Apply specialized data collection tools for observational data, forecasting, and modeling MAP environmental, social, health data NOT “new research” (usually)

HIA and Policy Sciences: Multiple Methods Focus on integrating/applying existing information Most HIAs elicit information from stakeholders Surveys Focus Groups Interviews Evidence summaries rate the ‘strength of evidence’ from literature, reports, case studies Recommendations based on weight of all evidence

Case Study 1: Paid sick days A Health Impact Assessment of the California Healthy Families, Healthy Workplaces Act of 2008 Does public health evidence support the hypothesized impacts of a mandatory requirement for paid sick days on health?

Paid Sick Days policy: Screening Nationally, 60 million lack paid sick days Potential benefits to individual, family and community health Limited legislative analysis of health Legislative sponsors enthusiastic about framing bill using health Methods exist to contribute to analysis CA legislation and HIA as national model

PSD Pathway Scoping Additional pathways for dependents completed as well

Paid Sick Leave: Health Advocates Help Win A Common Sense Policy (September 10, 2014) “Healthy Workplaces, Healthy Families Act” Imagine waking up sick with the flu. Wouldn’t you want to take a day off from work? What if not working meant going without pay? After July 1, 2015, fewer California workers will have to struggle with this choice. Last week, California Governor Jerry Brown signed AB 1522 making California the second state (after Connecticut) to guarantee most workers some paid sick leave. www.humanimpact.org In 2008, Human Impact Partners authored a health impact assessment on California’s first attempt to legislate paid sick days. …  Public health arguments were clearly central to last week’s passage of AB 1522… www.humanimpact.org

HIA and Policy Sciences: Social Process Participants: HIA often involves broader range of participants than official decision process Perspectives: Solicits different views on decision Situations: May create new forums for interaction; BUT HIA takes the policy context as given Base values: HIA process may enhance base values; recommendations may enhance scope values Strategies Diplomatic – integrate decision makers Ideological – public communication of recommendations Outcomes and Effects: emphasizes evaluation of: Process (how did it shape decision) Outcome (how did decision affect health determinants)

HIA And Policy Sciences: Health and Base Values Power: Highlighting health costs gives more power to groups suffering from health disparities Wealth: HIA connects economic security to better health, promoting interests of low income groups Enlightenment: Education is linked to better health outcomes; HIAs often support education improvments Skill: HIA may engage new groups in decision-making, improving their capacity for future participation Affection: Social connectedness, and community- building are well established health determinants Well-being: stress and poor mental health are important health outcomes and also affect physical health Respect and Rectitude: Participation, equity emphasis, and valuing community knowledge promote these Health evidence bases connect social determinants to health, so HIA may enhance…

HIA and Environmental Health Problem Solving Explicitly connects environment and health Integrating multiple sources of data Making use of available data Clarifying equity impacts of decisions Communicating policy consequences in health terms engages diverse stakeholders Health care reform: Clarifying health impacts (especially health disparities) = monetization Informing decisions, not “doing research”

Bringing HIA to Rochester Initiated by County Health Director(2009) National dialogue - Can HIA help Monroe County? Guide MCDOPH input to local decision makers? Childhood lead poisoning efforts were like HIA Shape health-promoting decisions; HIA “Learning Group” (2010) 40 participants Presentations, work groups, project planning Pew Health Impact Project grant (2012): Healthy Waterways City of Rochester’s Local Waterfront Revitalization Program “Healthy Waterways” HIA Rochester examples: College Town, School Modernization Plans, county transportation plan, project Green, HealthiKids

Applying HIA to Rochester’s Local Waterfront Revitalization Program

New York State’s Local Waterfront Revitalization Program Develop long-term plan for waterfront Guides decisions at all levels of government Opportunities for public involvement 13 policy statements Many relate to health Not required to consider health

Rochester’s LWRP 1990 LWRP; drafted update in 1999 Revision underway; expected completion 2014 Waterfront Advisory Committee (WAC) Involves City, County, Community, NYS DOS Once approved by NYS Department of State, applies to all activities within waterfront zone Communications Bureau, City of Rochester

Healthy Waterways: How might the LWRP impact health? What are the biggest health issues in Rochester? How do these relate to the waterfront? How could waterfront changes affect health? Goal: Make policy and planning recommendations to minimize health risks and maximize benefits in LWRP Communications Bureau, City of Rochester

LWRP “Elements” Assessed Waterfront trails Beaches Residential/commercial development Water-based recreation Stormwater management

ASSESSMENT METHODS: County health data Community surveys Stakeholder interviews Published literature Case studies First off, Health Impact Assessments (HIA) aim to… As part of the HIA of the LWRP, we have been inviting community partners to help us investigate links between the LWRP and ways to promote decisions and policies that improve the built environment and community health. Why SW Rochester? Since the proposed LWRP boundary follows the Genesee River north from the Erie Canal to Lake Ontario, and includes downtown Rochester. We are interested in the health and wellbeing of the people living in Southwest Rochester—a population that has direct access to the waterfront. The purpose of the survey was to collect data on the Southwest community’s health and wellbeing, and the impact that proposed plans/features of the Local Waterfront Revitalization Program may have on the health of the community. What will we do with data? Provide recommendations. Communications Bureau, City of Rochester

TRAIL USER SURVEYS/COUNTS 265 Trail users surveyed Demographics, trail use frequency Preferences for trail improvement COUNTS: 12 sites, 54 hours of observation Counted 2019 trail users User numbers vary by location National model estimates total use at sites from 25,000 to 300,000/year

WHO USES THE TRAIL? Demographically similar to County population EXCEPT: 69% male 44% walkers live less than half a mile from trail (locals) Incomes of local users close to City average 76% of local users use trail at least weekly Trail is an important exercise resource, especially for low income neighbors

40% of Rochester’s population lives in a ‘waterfront neighborhood’ Includes 45% of DEC “environmental justice” areas The mean income in PLEX, a southwest neighborhood , is a third lower than city average The PLEX low birth weight rate is nearly double that of the County Mean Years Potential Life Lost (YPLL) in PLEX is twice as high as County average

Physical Activity in Southwest Rochester 63% residents reported meeting CDC’s weekly recommended activity level (150 minutes exercise); similar to county mean 71% of whites 58% of blacks County health data show racial differences in obesity, heart disease, diabetes, etc. Obesity cost calculator “If the trail weren’t here, I wouldn’t exercise.” Due to time and space constraint of surveys, we did not ask participants to specify what kind of physical activity they participated in. So, the physical activity average values may be overestimated esp. because we included allowed walking as a form of physical activity. The CDC recommends adults to engage in moderate-intensity physical activity for 30 minutes or more on 5 or more days of the week, therefore, at least 150 minutes of moderate-intensity physical activity a week. 59% of participants reported that they engage in the recommended amount of physical activity. 53% Monroe County, 48% in NYS reported in the Monroe County Adult Health Survey. Referring to the 96% of participants who perceive their health to be very good or excellent, this emphasizes the need to disseminate the importance of adequate physical activity for a healthy lifestyle. Blacks (14, 54%) compared to Whites (24, 69%) were less likely to report they engage in the recommended amounts of physical activity. All physical activity responses was based on the past week’s physical activity. Note: we allowed walking as physical activity. TRAIL is more than a “recreation destination” – opportunity for physical activity and transportation by low income waterfront residents

Example: Trail Recommendations Policies: “Prioritize connecting trail through downtown and to adjacent neighborhoods” Projects: “Add amenities like better lights, water fountains, benches, fishing areas, or exercise equipment to encourage use” Programs: “Expand programs to encourage trail use by diverse populations, especially waterfront residents;” Communication: “Improve signage TO trail from neighborhoods and vice versa.” Monitoring: “Conduct annual trail user surveys”; “Establish trail management group to coordinate improvements, maintenance, use by neighbors and visitors”

SUMMARY: Healthy Waterways and the LWRP Health considered as a ‘goal’ in LWRP Community health data included in inventory and analysis Shifted focus from “destination” to include “waterfront neighbors” Recommendations integrated into LWRP subpolicies New partners identified for implementation (future grants, projects, planning, monitoring) Full report: bit.ly/QorjRS or http://www2.envmed.rochester.edu/envmed/EHSC/outreach/coec/projects/HIA/HealthyWaterways.html

Providence, RI Riverwalk In 1994, replaced the world’s widest bridge at 1,147 feet with new streets, cobblestone pathways, Venetian-style bridges, sculptures, fountains, boat landings, and parks including the four acre Waterplace Park with an open air auditorium. The Riverwalk hosts year round public art and cultural events Waterfire events regularly attract over 350,000 people. Hotel room rentals doubled between 1999 and 2000, and in August 2003 they rose over 50%. Payne, Thomas. Waterfire Providence Organization. 13 June 2012. Web. http://waterfire.org/about/history/

HIA and PSF: Decision Process Intelligence: HIA assessment Promotion: HIA reporting Prescription: HIA recommendations + assessed decision process Invocation: ?? Application: ?? Appraisal: HIA evaluation Termination: ??

What can PSF Bring to HIA Standpoint: Can one be ‘objective,’ ‘collaborative’, decision-relevant recommendations’ and ‘equity promoting’? Social process: HIA takes the “decision context” as fixed; other ‘situations’ may matter Decision process: HIA engages primarily in intelligence and promotion Helps explain frequent “recommendations beyond the recommendations.” Plan better for monitoring/evaluation of impact on decision, implementation, and health outcomes?

What can HIA contribute to PSF HIA is both an analysis and a process – limited, but broader than what would happen without it (partial application?) Language of health is easy to understand and has broad support; includes equity, participation, and well-being

Summary: HIA and PSF How is this framework compatible with a policy sciences perspective on problem solving? Goal = multimethod, problem-oriented, equity-promoting ways to improve of policy decisions What can/has the policy sciences contribute to this framework? Provide conceptual grounding for practice Heighten awareness of limits to HIA role in policy process What potential does this framework have for expanding the practice of the PSF (explicitly or not) Translation of ‘base values’ into ‘health language’ / data Cross walk into public health issues Growing field of ‘practicioners’ with problem orientation